Inspection Reports for
Bellgrade Estates
2800 Polo Pkwy, Midlothian, VA 23113, United States, VA, 23113
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Inspection Reports Summary
Covers 24 inspections · Jun 2021 – Dec 2025Visit Reason
This report covers 24 inspections of Bellgrade Estates Senior Living from June 23, 2021 to December 30, 2025, including routine, renewal, complaint, and monitoring inspections.
Complaint Details
Ten inspections were prompted by complaints regarding resident care and related services. Investigations sometimes supported allegations resulting in violations; other times no violations were found.
Findings
Across that history VDSS cited 63 violations under 44 distinct standards. 15 of 24 visits ended with violations and 9 with none. 10 inspections were prompted by a complaint.
Deficiencies (45)
22VAC40-73-460-H: Facility failed to ensure personal assistance and care met resident needs; resident found in soiled bedding.
22VAC40-73-650-A: Medication started, changed, or discontinued without valid physician order.
22VAC40-73-680-D: Medication not administered according to physician’s orders; multiple missed doses documented.
22VAC40-73-680-D: Medications not administered per physician instructions; missing documentation for Duopa medication.
22VAC40-73-70-A: Failed to report major incident to licensing office within 24 hours.
22VAC40-73-460-D: Failed to provide supervision of resident schedules, care, and activities including specialized needs.
22VAC40-73-870-B: Facility not free from foul odors; strong urine smell noted in bedroom #156.
22VAC40-73-550-G: Resident rights and responsibilities not reviewed annually for some residents.
22VAC40-73-380-A: Failed to document admission date on personal and social information form for several residents.
22VAC40-73-380-B: Personal and social information form not kept current after resident transfer.
22VAC40-73-940-A: Failed to comply with annual fire inspection requirement; last report dated 8/11/22.
22VAC40-73-560-E: Resident records not current, retained at facility, or kept locked; missing record for resident #11.
22VAC40-73-210-B: Direct care staff did not attend required 18 hours of annual training; staff #4 had 2.5 hours.
22VAC40-73-1080-B: Failed to obtain written approval for resident to reside in special care unit.
22VAC40-73-120-A: Staff orientation and training not verified within first seven working days for some staff.
22VAC40-73-560-I: No current picture or description for residents #5 and #9 for identification.
22VAC40-73-1110-B: Failed to perform six month or annual review of appropriateness of continued residence in special care unit.
22VAC40-73-450-F: Resident individualized service plans not reviewed or updated annually; missing 2023 ISP for some residents.
22VAC40-73-440-A: Uniform Assessment Instrument not updated at least annually; missing 2023 UAI for some residents.
22VAC40-73-440-A: Failed to update Uniform Assessment Instrument annually for resident #2 and #1.
22VAC40-73-680-B: Medications not kept in pharmacy container with label until administered; pills observed in cup.
22VAC40-73-450-C: Comprehensive individualized service plan did not include description of identified needs based on UAI.
22VAC40-73-450-A: Preliminary plan of care not developed on or within seven days prior to admission for some residents.
22VAC40-73-250-C: Failed to verify staff received current job description and orientation documentation.
22VAC40-90-40-B: Criminal history record report not obtained on or prior to 30th day of employment for some staff.
22VAC40-90-30-C: Staff made materially false statement on sworn statement or affirmation regarding convictions.
22VAC40-73-490-D: Licensed health care professional failed to certify healthcare oversight including dates and residents identified.
22VAC40-73-460-D: Failed to provide supervision of resident schedules, care, and activities including prevention of falls and wandering.
22VAC40-73-870-A: Interior of building not maintained in good repair and clean; stained and torn carpets noted.
22VAC40-73-450-E: Individualized service plans not signed and dated by resident or legal representative for multiple residents.
22VAC40-73-860-G: Hot water at taps not maintained within 105°F to 120°F; temperatures exceeded range in multiple rooms.
22VAC40-73-680-D: Medications not administered according to physician’s instructions; staff observed giving uncrushed meds contrary to orders.
22VAC40-73-250-D: Health information including tuberculosis exam and report not maintained in staff record for some staff.
22VAC40-73-450-C: ISP did not include description of identified needs and date based on admission physical exam and other sources.
22VAC40-73-680-D: Failed to administer medications in accordance with physician’s instructions; missing documentation on MAR.
22VAC40-73-300-B: Failed to utilize written communication to keep direct care staff informed of significant resident happenings including mental conditions.
22VAC40-73-450-A: Preliminary plan of care did not address basic needs adequately to protect resident health, safety, and welfare.
22VAC40-73-460-E: Failed to document notable changes in resident condition including altered behavior and corresponding actions taken.
22VAC40-73-650-B: Physician orders failed to identify diagnosis, condition, or specific indications for administering drugs.
22VAC40-73-680-I: Medication administration record did not include diagnosis, condition, or specific indications for drugs.
22VAC40-73-450-C: ISP did not include description of identified needs based on UAI; discrepancies noted between ISP and UAI.
22VAC40-73-680-D: Failed to administer medications per physician’s instructions; missing documentation of administration or omission.
22VAC40-73-150-F: Administrator did not serve full-time as on-site agent of licensee for facility licensed for residential and assisted living care.
22VAC40-73-130-A: Mandated reporters failed to report suspected abuse, neglect, or exploitation as required by law.
63.2-1808-A: Failed to treat residents with courtesy, respect, and consideration as persons of worth and dignity.
Report Facts
Violations cited: 63
Distinct standards: 44
Inspections on page: 24
Inspections with violations: 15
Complaint visits: 10
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